Donation of nonvital organs and tissue from living donors can increase the supply of organs available for transplantation, to the benefit of patients with end-stage organ failure. Enabling individuals to donate nonvital organs is in keeping with the goals of treating illness and relieving suffering so long as the benefits to both donor and recipient outweigh the risks to both.
Living donors expose themselves to harm to benefit others; novel variants of living organ donation call for special safeguards for both donors and recipients.
Physicians who participate in donation of nonvital organs and tissues by a living individual should:
- Ensure that the prospective donor is assigned an advocacy team, including a physician, dedicated to protecting the donor’s well-being.
- Avoid conflicts of interest by ensuring that the health care team treating the prospective donor is as independent as possible from the health care team treating the prospective transplant recipient.
- Carefully evaluate prospective donors to identify serious risks to the individual’s life or health, including psychosocial factors that would disqualify the individual from donating; address the individual’s specific needs; and explore the individual’s motivations to donate.
- Secure agreement from all parties to the prospective donation in advance so that, should the donor withdraw, his or her reasons for doing so will be kept confidential.
- Determine that the prospective living donor has decision-making capacity and adequately understands the implications of donating a nonvital organ, and that the decision to donate is voluntary.
- In general, decline proposed living organ donations from unemancipated minors or legally incompetent adults, who are not able to understand the implications of a living donation or give voluntary consent to donation.
- In exceptional circumstances, enable donation of a nonvital organ or tissue from a minor who has substantial decision-making capacity when:
- The minor agrees to the donation
- The minor’s legal guardians consent to the donation
- The intended recipient is someone to whom the minor has an emotional connection
- Seek advice from another adult trusted by the prospective minor donor when circumstances warrant, or from an independent body such as an ethics committee, pastoral service, or other institutional resource.
Inform the prospective donor:
- About the donation procedure and possible risks and complications for the donor
- About the possible risks and complications for the transplant recipient
- About the nature of the commitment the donor is making and the implications for other parties
- That the prospective donor may withdraw at any time before undergoing the intervention to remove the organ or collect tissue, whether the context is paired, domino, or chain donation
- That if the donor withdraws, the health care team will report simply that the individual was not a suitable candidate for donation
- Obtain the prospective donor’s separate consent for donation and for the specific intervention(s) to remove the organ or collect tissue.
- Ensure that living donors do not receive payment of any kind for any of their solid organs. Donors should be compensated fairly for the expenses of travel, lodging, meals, lost wages, and medical care associated with the donation only.
- Permit living donors to designate a recipient, whether related to the donor or not.
- Decline to facilitate a living donation to a known recipient if the transplantation cannot reasonably be expected to yield the intended clinical benefit or achieve agreed on goals for the intended recipient.
- Permit living donors to designate a stranger as the intended recipient if doing so produces a net gain in the organ pool without unreasonably disadvantaging others on the waiting list. Variations on donation to a stranger include:
- Prospective donors who respond to public solicitations for organs or who wish to participate in a paired donation (“organ swap,” as when donor-recipient pairs Y and Z with incompatible blood types are recombined to make compatible pairs: donor-Y with recipient-Z and donor-Z with recipient-Y)
- Domino paired donation
- Nonsimultaneous extended altruistic donation (“chain donation”)
- When the living donor does not designate a recipient, allocate organs according to the algorithm that governs the distribution of deceased donor organs.
- Protect the privacy and confidentiality of donors and recipients, which may be difficult in novel donation arrangements that involve many patients and in which donation-transplant cycles may be extended over time (as in domino or chain donation).
- Monitor prospective donors and recipients in proposed nontraditional donation arrangements for signs of psychological distress during screening and after the transplant is complete.
- Support the development and maintenance of a national database of living donor outcomes to support better understanding of associated harms and benefits and enhance the safety of living donation.
AMA Principles of Medical Ethics: I, V, VII, VIII
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